1. The Field of the Invention
The present invention relates to systems for creating and approving health insurance claims. More particularly, the present invention relates to interactively creating insurance claims on a client computer that communicates with a remote server computer, whereby a health care provider can be almost immediately informed whether the created insurance claim is in condition to be paid.
2. Relevant Technology
The cost of health care continues to increase as the health care industry becomes more complex, specialized, and sophisticated. The proportion of the gross domestic product that is accounted for by health care is expected to gradually increase over the coming years as the population ages and new medical procedures become available. Over the years, the delivery of health care services has shifted from individual physicians to large managed health maintenance organizations. This shift reflects the growing number of medical, dental, and pharmaceutical specialists in a complex variety of health care options and programs. This complexity and specialization has created large administrative systems that coordinate the delivery of health care between health care providers, administrators, patients, payors, and insurers. The cost of supporting these administrative systems has increased during recent years, thereby contributing to today""s costly health care system.
A significant portion of administrative costs is represented by the systems for creating, reviewing and adjudicating health care provider payment requests. Such payment requests typically include bills for procedures performed and supplies given to patients. Careful review of payment requests minimizes fraud and unintentional errors and provides consistency of payment for the same treatment. However, systems for reviewing and adjudicating payment requests also represent transaction costs which directly reduce the efficiency of the health care system. Reducing the magnitude of transaction costs involved in reviewing and adjudicating payment requests would have the effect of reducing the rate of increase of health care costs. Moreover, streamlining payment request review and adjudication would also desirably increase the portion of the health care dollar that is spent on treatment rather than administration.
Several factors contribute to the traditionally high cost of health care administration, including the review and adjudication of payment requests. First, the volume of payment requests is very high. Large health management organizations may review tens of thousands of payment requests each day and tens of millions of requests yearly. In addition, the contractual obligations between parties are complex and may change frequently. Often, there are many different contractual arrangements between different patients, insurers, and health care providers. The amount of authorized payment may vary by the service or procedure, by the particular contractual arrangement with each health care provider, by the contractual arrangements between the insurer and the patient regarding the allocation of payment for treatment, and by what is considered consistent with current medical practice.
During recent years, the process of creating, reviewing, and adjudicating payment requests from health care providers has become increasingly automated. For example, there exist claims processing systems whereby technicians at health care providers"" offices electronically create and submit medical insurance claims to a central processing system. The technicians include information identifying the physician, patient, medical service, insurer, and other data with the medical insurance claim. The central processing system verifies that the physician, patient, and insurer are participants in the claims processing systems. If so, the central processing system converts the medical insurance claim into the appropriate format of the specified insurer, and the claim is then forwarded to the insurer. Upon adjudication and approval of the insurance claims, the insurer initiates a check to the provider. In effect, such systems bypass the use of the mail for delivery of insurance claims.
In partially automated systems, such as that described in the foregoing example, the technician can submit a claim via electronic mail on the Internet or by other electronic means. To do so, the technician establishes communication with an Internet service provider or another wide area network. While communication is maintained, the technician sends the insurance claim to a recipient and then either discontinues communication or performs other activities while communication is established. Using such conventional systems, personnel at the health care provider""s office are unable to determine whether the submitted claim is in condition for payment and do not receive any indication, while communication is maintained, whether the claim will be paid.
Thus, while systems that permit electronic submission of insurance claims marginally decrease the time needed to receive payment by eliminating one or more days otherwise required to deliver claims by mail, they remain subject to many of the problems associated with other claims submission systems. For example, it has been found that a large number of insurance claims are submitted with information that is incomplete, incorrect, or that describes diagnoses and treatments that are not eligible for payment. The claims can be rejected for any of a large number of informalities, including clerical errors, patient ineligibility, indicia of fraud, etc. The health care provider is not made aware of the deficiencies of the submitted claims until a later datexe2x80x94potentially weeks afterwardsxe2x80x94when the disposition of the insurance claim is communicated to the health care provider. As a result, many claims are subject to multiple submission and adjudication cycles, as they are successively created, rejected, and amended. Each cycle may take several weeks or more, and the resulting duplication of effort decreases the efficiency of the health care system. Studies have shown that some insurance claim submission systems reject up to 70% of claims on their first submission for including inaccurate or incorrect information or for other reasons. Many of the claims are eventually paid, but only after they have been revised in response to an initial rejection.
In order to attempt to minimize the number of claims that are rejected, physicians or their staff have had to spend inordinate amounts of time investigating which treatments will be covered by various insurers and insurance plans. The time spent in such activities represents further efficiency losses in the health care system.
Depending on a patient""s insurance plan and the diagnosis and treatment rendered, the patient may be required to make a co-payment representing, for example, a certain percentage of the medical bill or a fixed dollar amount. Because of the large number of insurers and insurance plans, the amount of the co-payment can vary from patient to patient and from visit to visit. Moreover, when a patient is not covered for certain treatment, the patient may be liable for the entire amount of the health care services. It is sometimes difficult for technicians at the offices of the health care provider to determine that amount of any co-payment or any other amount due from the patient while the patient remains at the offices after a medical visit. Once the patient leaves the office, the expense of collecting amounts owed by patients increases and the likelihood of being paid decreases. Conventional insurance claim submission systems have not been capable of efficiently and immediately informing technicians at the offices of a health care provider of amounts owed by patients, particularly when the amount is not a fixed dollar amount.
In view of the foregoing, there is a need in the art for more fully automated claims processing systems. For example, it would be an advancement in the art to reduce the uncertainty as to whether a claim to be submitted is likely to be paid or rejected. Furthermore, it would be advantageous to provide a claims processing system that would more easily allow health care providers to know what patient and treatment information must accompany insurance claims. There also exists a need for systems that allow health care providers to easily learn of the status of submitted insurance claims.
The present invention relates to methods and systems for interactively creating insurance claims. According to the invention, a medical technician can prepare an insurance claim electronically, submit the claim via the Internet or another wide area network, and receive almost immediately an indication whether the submitted claim is in condition to be paid. If the medical technician is informed that the claim is not in condition to be paid, the claim can be amended by correcting errors or otherwise placing the claim in condition to be paid. By using the invention, health care providers can essentially eliminate the possibility of having claims rejected after a lengthy adjudication process. The invention can significantly reduce the time, effort, and expense that have been associated with the submission of claims that are not in condition to be paid.
According to the invention, communication is established between a client computer operated by a medical technician and a remote server computer. The communication can be established using the Internet, a direct-dial telephone line, or any other suitable wide area network infrastructure. The client computer displays a computer-displayable claim form to the medical technician. The claim form can be sent to the client computer by the remote server or can instead be retrieved from a local memory device. The claim form includes fields that permit the medical technician to enter patient identification information that identifies the patient. The patient identification information is transmitted from the client computer to the remote server. The remote server then determines whether the patient is a beneficiary of a health insurance plan and informs the client computer of the patient eligibility status.
Informing the medical technician almost immediately of the patient""s insurance status allows the health care provider to select the appropriate treatment for the patient. The patient""s eligibility status transmitted from the remote server can include any desired amount of detail. For example, the eligibility status can describe the types of diagnoses and treatments for which payment will be made on behalf of the patient, and the co-payment required by the patient.
If the patient is a beneficiary of an approved insurance plan, the medical technician can proceed with preparation of a full insurance claim. The claim form displayed by the client computer includes fields that permit the medical technician to enter one or more diagnosis codes describing the diagnosis of the patient and one or more treatment codes describing the treatment administered to the patient. The claim form can also include fields representing the identity of the health care provider and any other desired information.
The diagnosis and treatment codes are transmitted from the client computer to the remote server. The remote server or a processor associated therewith then processes the transmitted information to determine whether the insurance claim is in condition to be paid. For example, the remote server can verify that all required information is included. The remote server can also determine whether the diagnosis code and the treatment code correspond to currently accepted medical practice and to health care services that are covered by the particular insurance plan of the patient. The remote server can also perform any desired checks on the information in the insurance claim to determine whether the claim has indicia of fraud, unusually expensive treatment, or any other feature that indicates that the validity or accuracy of the claim should be further investigated.
If the insurance claim is not in condition to be paid, the remote server transmits information to the client computer to inform the medical technician. The information transmitted to the client computer can include an indication of the reason for rejection of the claim and, optionally, suggestions on how to remedy the problem. For instance, if the insurance claim does not include complete information, the medical technician can be prompted to complete the claim form. The deficiency of the claim can be substantive, as well, in that the treatment code could represent a treatment that is not considered to be compatible with the diagnosis. In this case, the health care provider can change the treatment, otherwise amend the claim form, or inform the patient that the insurance plan will not cover the treatment. When a claim form has been amended, the new information can be transmitted to the remote server to repeat the process of determining whether the claim is in condition to be paid.
When the remote server determines that the claim is in condition to be paid, the remote server transmits information to the client computer to notify the medical technician. The information transmitted to the client computer can include data that represents an amount that is to be paid by the insurer on behalf of the patient. The medical technician can also be informed of any co-payment to be collected from the patient. Because the process of determining whether the claim is in condition for payment can occur almost instantaneouslyxe2x80x94typically in a matter of seconds or minutesxe2x80x94any co-payment can be collected from the patient while the patient remains in the offices of the health care provider before or after treatment.
In view of the foregoing, the invention provides systems and methods for providing almost immediate feedback to the medical technician specifying whether a submitted claim is in condition to be paid. While the speed of response can vary, depending on the data transmission rates between the client computer and the remote server, the processing capabilities of the remote server, and the complexity of the verification process to be conducted by the remote server, the invention can provide almost immediate response to submitted claims. The response time can be short enough that the medical technician can create a claim, submit the claim, and be notified whether the claim is in condition for allowance without discontinuing communication between the client computer and the remote server, while continuing to view the claim form displayed by the client computer, or without proceeding to another patient""s claim before receiving the response. In any event, the response time is significantly faster than that of conventional systems, which do not permit the interactive creation and modification of insurance claims.
The invention can significantly reduce the inefficiencies that are otherwise experienced in the health care system as claims are submitted, subjected to an adjudication process, and often rejected days, weeks, or longer, after the claim was created. The claim creation and verification systems of the invention also allow health care providers to easily learn of the types of treatments that are approved for payment for specific diagnoses according to the patient""s insurance plan. In addition, the invention increases the efficiency of collecting co-payments from patients and increases the likelihood that such co-payments will be made.
Additional objects and advantages of the invention will be set forth in the description which follows, and in part will be obvious from the description, or may be learned by the practice of the invention. The objects and advantages of the invention may be realized and obtained by means of the instruments and combinations particularly pointed out in the appended claims. These and other objects and features of the present invention will become more fully apparent from the following description and appended claims, or may be learned by the practice of the invention as set forth hereinafter.